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Xavier University - Ateneo de Cagayan

COLLEGE OF NURSING
Cagayan de Oro City, Philippines

VISION
STATEMENT Teaching-Learning Guide: N 107.2 & N 108.1 Enhancements
To be a
leading ASEAN Topic IV Therapy
University
forming leaders Entry Competencies:
of character by Prior to the discussion, the student shall have acquired knowledge, skills & attitude in the care of clients across the lifespan with IV Therapy.
2033.
Time N 107.2 & N 108.1 (Classroom Guide)
Frame
MISSION Teaching-Learning References Evaluation
STATEMENT
Week Learning Outcomes Content Activities
Xavier Univer-
(Time allotment)
sity (Ateneo de
Cagayan) 1 Given a hypothetical or actual scenario or I.A Definition Intravenous therapy is the (1 hour) First Rotation
forms men and situation related to the intravenous therapy, giving of liquid substance directly into a vein. It RLE 10-30pt quiz
women of the students will be able to: can be intermittent or continuous or also Student Input: Procedures
competence, known as intravenous drip. Compilation for Paper & pen tests
conscience and
a. Define intravenous insertion and its Indication: Intravenous fluid therapy is used to PPT presentation BSN4
commitment in
service of the indication, purpose and equipment maintain fluid homeostasis and replace any Enhancement
church, the needed. additional losses. Demonstration & Perry, A. & Rubrics
Global b. Discuss different kinds of Purpose: 1. To supply fluid when clients are Return Potter, P.
community and intravenous (IV) solutions and unable to take adequate volume by mouth. Demonstration (2014). Clinical
the Filipino intravenous (IV) catheter gauges 2. To provide salts and other electrolyte Nursing Skills
people. according to their respective color, needed to maintain electrolyte balance Gamefication (IV and
size and indication. 3. To establish a lifeline for rapidly needed Solution and Techniques.
c. Demonstrate & return demonstrate medications. Catheter, IV 8th edition. St
the proper procedure with rationale Equipments needed: IV Catheter, IV tubing, IV Therapy Louis,
in assisting insertion by a RN. Solution, IV Pole, Sterile drape, Torniquette, Complications) Missouri.
d. Identify complications of IV Plaster, Kidney Basin, Alcohol swab, Arm Elsevier Mosby
therapy. Splint, Clean Gloves. Additionals: Blood Bag,
e. Demonstrate and return Soluset.
demonstrate techniques on
Orig COURSE OUTLINE Template Prepared by XUCAT. Revised with permission by MGM P May 2011. TLG N 107.2 & N 108.1 1
Xavier University - Ateneo de Cagayan
COLLEGE OF NURSING
Cagayan de Oro City, Philippines

terminating IV line. I.B Types of IV Solutions and their respective


f. Emphasize the importance of color and category:
maintaining sterility of the Hypotonic:
procedure. 0.45% NS- White
0.33% NS- White
Isotonic:
D5W- Red
PLR- Dark Blue
D5NSS- Yellow
PNSS- Green
Hypertonic:
D5IMB- Violet
D5NM- Orange
D5NR- Yellow Green
D5LR- Pink
D5 0.3% NaCl- Light Blue

Types of IV catheters and their respective


color and indication:
#14G- orange
#16G- grey
#17G-white
#18G-green
#20G-pink
#22G-blue
#24G-yellow
#26G-dark blue

I.C Assisting in initiating Intravenous Therapy


Assessment
Diagnosis
Planning
Implementation
Orig COURSE OUTLINE Template Prepared by XUCAT. Revised with permission by MGM P May 2011. TLG N 107.2 & N 108.1 2
Xavier University - Ateneo de Cagayan
COLLEGE OF NURSING
Cagayan de Oro City, Philippines

Evaluation
(for detailed content refer to Appendix Table 1)

I.D Common IV complications


(for (for detailed content refer to Appendix
Table 2)

I.E Terminating Intravenous Therapy


Assessment
Diagnosis
Planning
Implementation
Evaluation
(for detailed content refer to Appendix Table 3)

Prepared by: BSN 4 A2 Supervising Clinical Instructor: Pinque, Mildred, RN, MN


Level IV Students Level IV Clinical Instructor

MECHANICS:
1. BSN4 SNs to prepare TLG for the assigned topics; one TLG per topic
2. CIs to supervise the enhancement
2.1. collect the completed TLGs from BSN4 SNs
2.2. facilitate the SNs presentations during the enhancement sessions
2.3. grade the presentations using rubric
2.4. tests the SNs through paper and pen test/quiz (10-30 items per week);
3. Focus on issues, concerns and innovations related to the topics considered;
4. Case presentations per group to be facilitated during enhancement session (per agreed time by CI and SNs MT period);
5. Q&A Drills topics to align with CA2 calendar;
5.1. Each SN to prepare test items (1-10) with rationale and shares these with the group
5.2. Teaching-learning activities may vary in the drill: ppt presentation, games, etc
6. completed TLGs should be submitted to the supervising CI week prior to scheduled presentation;
Orig COURSE OUTLINE Template Prepared by XUCAT. Revised with permission by MGM P May 2011. TLG N 107.2 & N 108.1 3
Xavier University - Ateneo de Cagayan
COLLEGE OF NURSING
Cagayan de Oro City, Philippines
7. For other concerns, please approach CI-in- charged or the level coordinator.

Prepared by: Paayas, Mary Grace M., RN, MAN


Level IV Coordinator

Appendix

Table 1. Assisting in Initiating Intravenous Therapy


STEPS RATIONALE
ASSESSMENT:
Take the vital signs of the patient. For baseline data.
Status of veins to determine appropriate venipuncture site. Avoid sites that have Recently used sites will be more prone to complications and discomfort.
been used recently.
Determine if the client is right- or left-handed. Do not use the dominant hand if possible.
Assess clinical markers of interstitial volume:
a. Clinical markers of interstitial volume (1) Skin turgor (Pinch skin over sternum Failure of skin to return to normal position within 3 seconds indicates ECV
or inside of forearm.) deficit. This is called tenting (Alexander et al., 2010).

Pitting edema is seen with a weight gain of 10 to 15 lbs (4.5-6.8 kg) of retained
b. Dependent edema (pitting or nonpitting) fluid (Alexander et al., 2010).

More reliable indicator than dry lips or skin. Dry between cheek and gums
c. Oral mucous membrane between cheek and gum. indicates ECV deficit.
PLANNING:
Prior to initiating the IV infusion, consider how long the client is likely to have the These factors may affect the choice of vein and catheter size. Review the client
IV, what kinds of fluids will be infused, and what medications the client will be record regarding previous infusions. Note any complications and how they
receiving or is likely to receive. were managed.
IMPLEMENTATION:
Preparation:
If possible, select a time to perform the venipuncture that is convenient for the Moving the limb after the infusion has been established could dislodge the
client. Unless initiating IV therapy is urgent, provide any scheduled care before catheter.
establishing the infusion to minimize excessive movement of the affected limb.

Orig COURSE OUTLINE Template Prepared by XUCAT. Revised with permission by MGM P May 2011. TLG N 107.2 & N 108.1 4
Xavier University - Ateneo de Cagayan
COLLEGE OF NURSING
Cagayan de Oro City, Philippines

Procedure:
Explain to the client what you are going to do, why it is necessary, and how she To gain cooperation from the client.
can cooperate.
Wash hands and observe other appropriate infection control procedure. To prevent contamination and the spread of microorganisms.
Provide for client privacy.
Open and prepare the infusion set.
- Remove tubing from the container and straighten it out.
- Slide the tubing clamp along the tubing until it is just below the drip chamber to
facilitate its access.
- Leave the ends of the tubing covered with the plastic caps until the infusion is This will maintain the sterility of the ends of the tubing.
started,
Spike the solution container,
- Remove the protective cover from the entry site of the bag.
- Remove the cap from the spike and insert the spike into the insertion site of
the bag or bottle. Follow manufacturers instructions.
Apply a medication label to the solution container if a medication is added. The label is applied upside down so it can be read easily when the container is
hanging up.
Apply a timing label on the solution container. The timing label may be applied at the time the infusion is started, Follow
agency practice.
Hang the solution container on the pole. Adjust the pole so that the container is This height is needed to enable gravity to overcome venous pressure and
suspended about 1m (3ft) above the clients head. facilitate flow of the solution into the vein.
Partially fill the drip chamber with solution. Squeeze the chamber gently until it The drip chamber is partially filled with solution to prevent air from moving
is half full of solution. down the tubing.
Prime the tubing.
- Remove the protective cap and hold the tubing over a container. Maintain the
sterility of the end of the tubing and the cap.
- Release the clamp and let the fluid run through the tubing until all bubbles are
removed. Tap the tubing if necessary with your fingers to help the bubbles The tubing is primed to prevent the introduction of air into the client. Air
move. bubbles smaller than 0.5 mL usually do not cause problems in peripheral lines.
- Reclamp the tubing and replace the tubing cap, maintaining sterile technique.
- If an infusion control pump, electronic device, or controller is being used,

Orig COURSE OUTLINE Template Prepared by XUCAT. Revised with permission by MGM P May 2011. TLG N 107.2 & N 108.1 5
Xavier University - Ateneo de Cagayan
COLLEGE OF NURSING
Cagayan de Oro City, Philippines

follow the manufacturers directions for inserting the tubing and setting the
infusion rate.
Perform hand hygiene again just prior to client contact.
Select the venipuncture site.
- Unless contraindicated, use the clients nondominant hand.
- Check agency protocol about shaving if the site is very hairy.
- Place a towel or bed protector under the extremity to protect linens. Shaving can cause microabrasions that can increase the risk of infection.
Dilate the vein.
- Place the extremity in a dependent position (lower than the clients heart). Gravity slows venous return and distends the veins. Distending the veins
makes it easier to insert the needle properly.
- Apply a tourniquet firmly 15 to 20 cm (6 to 8 in.) above the venipuncture site. - The tourniquet must be tight enough to obstruct venous flow but not so tight
that it occludes arterial flow. Obstructing arterial flow inhibits venous filling.

- If the vein is not sufficiently dilated:


Massage or stroke the vein distal to the site and in the direction of
venous flow towards the heart.
Encourage the client to clench and unclench the fist.
Lightly tap the vein with your fingertips. Tapping may distend the vein.
- If the preceding steps fail to distend the vein so that it is palpable, remove the
tourniquet and wrap the extremity in a warm towel for 10 to 15 minutes.

Heat dilates superficial blood vessels, causing them to fill. Then repeat steps to
dilate the vein.
Apply clean gloves and clean the venipuncture site. Gloves protect the nurse from contamination by the clients blood.
- Clean the skin at the site of entry with a topical antiseptic swab (e.g., 2%
chlorhexidine, or alcohol). Check for allergies to iodine or shellfish before
cleansing skin with Betadine or iodine
Products.
- Use a circular motion, moving from the center outward for several inches. This motion carries the microorganisms away from the site of entry.
- Permit the solution to dry on the skin. Povidone iodine should be in ontat with
the skin for 1 minute to be effective.
Insert the catheter and initiate the infusion.
Orig COURSE OUTLINE Template Prepared by XUCAT. Revised with permission by MGM P May 2011. TLG N 107.2 & N 108.1 6
Xavier University - Ateneo de Cagayan
COLLEGE OF NURSING
Cagayan de Oro City, Philippines

- Use the nondominant hand to pull the skin taut below the entry site. This stabilizes the vein and makes the skin taut for needle entry. It can also
make initial tissue penetration less painful.
- Holding the over-the-needle catheter at a 15- to 30-degree angle with needle
(stylet) bevel up, insert the catheter through the skin and into the vein in one
thrust.
- Once blood appears in the lumen or clear flashback chamber of the needle,
lower the angle of the catheter until it is almost parallel with the skin, and The catheter is advanced to ensure that it, and not just the stylet, is in the vein.
advance the needle (stylet) and catheter approximately 0.5 to 1 cm (about 1/4
in.) farther. Holding the needle assembly steady, advance the catheter until the
hub is at the venipuncture site.
- Release the tourniquet.
- Remove the protective cap from the distal end of the tubing, and hold it ready
to attach to the catheter, maintaining the sterility of the end.
- Carefully remove the needle, engage the needle safety device, and attach the
end of the infusion tubing to the catheter hub.
- Initiate the infusion.
Tape the catheter.
- Tape the catheter by the U method. Using three strips of adhesive tape, each
about 7.5 cm (3in) long:
Place one strip, sticky-side up, under the catheters hub.
Fold each end over so that the sticky sides are against the skin.
Place second strip, sticky-side down, over catheter hub.
Place third strip, sticky-side down, over tubing hub.
Dress and label the venipuncture site and tubing according to agency policy.
- Cover venipuncture site according to policy.
- Remove the soiled gloves and discard appropriately.
- Loop the tubing and secure it with tape.
- Label the dressing with the date and time of insertion, type and gauge of
needle or catheter used, and your initials.
Ensure appropriate infusion flow/
- Apply a padded arm board to splint the joint as needed.

Orig COURSE OUTLINE Template Prepared by XUCAT. Revised with permission by MGM P May 2011. TLG N 107.2 & N 108.1 7
Xavier University - Ateneo de Cagayan
COLLEGE OF NURSING
Cagayan de Oro City, Philippines

- Adjust the infusion rate of flow according to the order.


Label the IV using the IV tag.
Document relevant data. Record:
- The time of the start of infusion.
- The flow of rate of the transfusion.
- The date and time of the venipuncture.
- The amount and type of solution usedm including any additives.
- The type and gauge of the needle or catheter,
- The venipuncture site.

Table 2. Common IV Complications


LOCAL SYSTEMIC
Infiltration Embolism (Pulmonary, Air or
Extravasation Catheter)
Thrombosis Hematoma
Thrombophlebitis Systemic Infection
Phlebitis Circulatory Overload
Allergic Reaction

Table 3. Terminating Intravenous Therapy


STEP RATIONALE
ASSESSMENT:
Assess the appearance of the venipuncture site, signs of bleeding, amount of fluid Ensure that the procedure is to be performed is safe to carry out.
infused and appearance of the IV catheter.

Review the physicians order and check clients identification band. Ensure complete voluntarism and approval to undergo the procedure.
PLANNING:
Introduce self and verify clients identity using hospital protocol. Explain what the Ensure patients comfort throughout the procedure.
client needs to know about the procedure to be performed and why it is necessary.

Orig COURSE OUTLINE Template Prepared by XUCAT. Revised with permission by MGM P May 2011. TLG N 107.2 & N 108.1 8
Xavier University - Ateneo de Cagayan
COLLEGE OF NURSING
Cagayan de Oro City, Philippines

Gather equipment, set up tube-feeding equipment or suction equipment mentioned Confirm availability of supplies needed.
above
IMPLEMENTATION:
Draw the curtains if the client is admitted in a ward or close the door if in a private Maintain client privacy.
room.
Perform proper handwashing and don clean disposable gloves. Observe medical asepsis before starting the procedure.

Position the client comfortably in a sitting or lying position. Ensure appropriate positioning of the client.

Perform the procedure in a well-lit place Ensure adequate lighting.

Stop the flow of the infusion by closing the roller clamp, if an infusion is ongoing. Ensure that the bed linens and the client himself will remain dry.

Moisten adhesive tapes around the IV catheter with cotton balls with alcohol and Prevent possible causes of injury and discomfort to the client.
remove the tape at the venipuncture site while holding the cannula firmly and
applying counter-traction to the skin
Withdraw the cannula from the vein. Pull it out in line with the vein.
Stop bleeding and prevent hematoma formation
Apply firm pressure to the site using a sterile gauze or cotton ball for a good 2-3
min. Hold or elevate clients arm above the level of the heart if bleeding persists
Ensure that the cannula is removed completely.
Examine the cannula removed from the client if it is intact.
Maintain sterility and reduce risk of infection
Place a sterile dressing over the venipuncture site

Discard all waste materials including the IV cannula according to Health Care Apply after-care
Waste Management and perform hand hygiene.

Orig COURSE OUTLINE Template Prepared by XUCAT. Revised with permission by MGM P May 2011. TLG N 107.2 & N 108.1 9
Xavier University - Ateneo de Cagayan
COLLEGE OF NURSING
Cagayan de Oro City, Philippines

EVALUATION:
Assess the puncture sire in 15 min. to ensure that no bleeding has occurred. Check for bleeding on the site.
Instruct patient to avoid vigorous activities with the affected extremity for at least
15 min. following removal of device.Instruct patient to call the nurse if bleeding
occurs.

Record time, site and type of needle terminated and reason for termination, Ensure complete documentation of the procedure done.
condition of catheter/needle, assessment of venipuncture site, amount of solution
infused (if appropriate), and all patient teacher done as well as clients response.

Distinguish related nursing interventions for unexpected outcomes Analyze possible nursing interventions for unexpected outcomes.

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